Periodontal Therapy (Full Version)

PERIODONTAL THERAPYConsists of: •PHASE I• PHASE II• PHASE III• PHASE IV

E & D TREATMENT PLANNING

TREATMENT

INITIAL PHASE REASSESSMENT CORRECTIVE PHASE

SURGICAL PROCEDURES

RECONSTRUCTIVE PROCEDURES

OHE BEHAVIORAL CHANGE

PROPHYLAXIS DEBRIDEMENT

OTHER DENTAL TREATMENT

SUPPORTIVE PERIODONTAL CARE

PHASE 1

Phase I therapy is referred to by many names;•Initial / first line therapy•Nonsurgical periodontal therapy•Cause-related therapy•Etiotropic phase of therapy

PHASE 1

AIM of Therapy;

Elimination & prevention of recurrence of supra / subgingivally located bacterial deposits.

Rationale

• Reduction & elimination of etiologic & contributing factors in periodontal treatment are achieved by;

- complete removal of calculus- Correction of defective restoration- Treatment of carious lesion- Comprehensive daily plaque control regimen

• Provided to all patients with periodontal pockets who later will be evaluated for surgical intervention (gingivitis / mild chronic periodontitis).

PHASE 1

PHASE 1Components:

• Relief pain• Patient education

& motivation• Behavioral change• Plaque control &

oral hygiene care• Prophylaxis• Scaling & root

debridement• Chemical control of

plaque deposition

• Correction/ replacement of poorly fitting restorations & prosthetic devices

• Restorations of carious lesions

• Orthodontic tooth movements

• Treatment of occlusal trauma

• Endodontic treatment

• Extraction of hopeless teeth

OHE – Patient InformationIndications:- Low oral health knowledge,

awareness, motivation & compliance.- Poor self performed plaque control,

smoking & other psychosocial behaviors.

- High risk individuals to plaque – induced diseases.

PHASE 1

• OHE – Patient Information- To provide information about dental

health – demonstration to the patient of the disease present in the mouth.

- To provide information & guidance about the techniques of plaque control.

PHASE 1

• OHE – Patient Motivation- Change in knowledge- Change in understanding- Change in attitude- Change in habit- Use simple everyday language &

avoid jargons

PHASE 1

• Behavioral Change- Diet counseling – encourage

balanced diet and frequency.- Smoking cessation (smoking – risk

factor for periodontitis), it will increase in progression of disease, alter the fibroblast function & impair wound healing.

PHASE 1

• OHI- Tooth brushing method:

PHASE 1

• Roll – roll method or Modified Stillman technique• Vibratory – Bass Technique• Circular – Fones Technique• Vertical – Leonard Technique• Horizontal – Scrub Technique

• Roll – roll method or Modified Stillman technique• Vibratory – Bass Technique• Circular – Fones Technique• Vertical – Leonard Technique• Horizontal – Scrub Technique

• OHIRecommendation of toothbrush

design:- Soft- Nylon bristle- Toothbrushes need to be replaced

about every 3 months (or replace when it start to show sign of matting).

PHASE 1

• OHI- Powered toothbrush – also can

remove plaque effectively (properly used).

- Patients need to be instructed in the proper use of powered devices.

- Patients who are poor brushers, children & caregivers may particularly benefit from using powered toothbrushes.

PHASE 1

• OHI – Interdental Cleaning Aids- Cleans the interdental region (most

common site for plaque retention).- Most inaccessible site to tooth

brushing.- Dental floss- Interdental space brush

PHASE 1

• OHI – Interdental Cleaning Aids (Dental Floss)

Technique;- 12 – 18 inches of floss wrapped around the

fingers / the ends may be tied together in a loop.- Stretch the floss tightly between the thumb &

forefinger/ between both forefingers & pass it gently through each contact area with a firm back-and-forth motion.

- Move the floss across the interdental gingiva & repeat the procedure on the proximal surface of the adjacent tooth.

PHASE 1

• Prophylaxis- Removal of supragingival plaque &

calculus (scaling & polishing).- Removal of plaque retentive factors;Smooth roughness of restorationRemoval of overhangsIll-fitting / rough prosthesisRemoval of staining

PHASE 1

Non – surgical Instrumentation

Scaling – procedure of removal of plaque & calculus from the tooth surface.

Root debridement – hard/ powered driven subgingivally instrumentation aimed at removal of toxic substances without overinstrumentation / intentional removal of cementum to produce a root that is biologically acceptable for a healthy attachment.

PHASE 1

Non – surgical Instrumentation- Chemotherapeutic approaches Topical application of antiseptics –

to prevent plaque accumulation & to disinfect the root surfaces.

Mouthrinses –ChlorhexidineChip-perio chipSolution injection – elyzol/periocline

PHASE 1

Non – surgical Instrumentation- Chemotherapeutic approaches Systemic approach – selective use of

antibiotic or host modulation of tissue destructive enzymes (Doxycycline).

Rationale; Pathogenic organisms that were not

accessible to mechanical removal by hand/power driven instruments can be reduced/eliminated.

PHASE 1

Treatment Sessions- The following conditions must considered

to plan Phase 1 treatment sessions needed;

PHASE 1

General health & tolerance of treatmentNumber of teeth present amount of subgingival calculusProbing pocket depths & attachment lossFurcation involvement

General health & tolerance of treatmentNumber of teeth present amount of subgingival calculusProbing pocket depths & attachment lossFurcation involvement

Alignment of teethMargins of restorationsDevelopmental anomaliesPhysical barriers to access (limited opening / tendency to gag) Patient cooperation & sensitivity (requiring anesthesia / analgesia)

Alignment of teethMargins of restorationsDevelopmental anomaliesPhysical barriers to access (limited opening / tendency to gag) Patient cooperation & sensitivity (requiring anesthesia / analgesia)

• Step 1 (Limited Plaque Control Instruction)

- Should start in 1st appointment & should include only the correct use of toothbrush on all surfaces of the teeth.

- Use of dental floss should await the removal of calculus & overhanging restorations.

PHASE 1

• Step 2 (Supragingival Removal of Calculus)

- Can be done by scalers, curettes or ultrasonic instrumentation.

PHASE 1

• Step 3 (Recountouring Defective Restorations & Crowns)

- May require replacing the entire restoration or crown or correcting it with finishing burs or diamond-coated files mounted on the special handpiece.

PHASE 1

• Step 4 (Obturation of Carious Lesion)

- Involves complete removal of the carious tissue & placement of final or a temporary restoration.

PHASE 1

• Step 5 (Comprehensive Plaque Control Instrumentation)

- Patient should learn to remove plaque completely from all supragingival areas, using toothbrush, floss & other necessary complementary method.

PHASE 1

• Step 6 (Subgingival Root Treatment)

- Complete calculus removal & root planning can be effectively performed.

PHASE 1

• Step 7 (Tissue Reevaluation)- The periodontal tissue reexamined to

determine the need for further therapy.

- Pocket are reprobed & all related anatomical conditions are carefully evaluated to decide whether surgical treatment is indicated.

PHASE 1

LIMITATIONS of NON-SURGICAL TREATMENT

• Requires skill, practice & patience – ‘blind’ tactile sensibility has to be developed to achieve smooth root surface.

• Root proximity & rotation, concavities & ridges, groove, furcation & pits all causing cleaning problems.

PHASE 1

CHEMICAL PERIODONTAL THERAPY

•Roles of chemical agents (antiseptic & antibiotic) in periodontics•The different of chemical plaque agent•Content, indication, limitation & effects of use of these agents


GOAL –

• Removal of supragingival & subgingival bacteria.

• Supragingival plaque – accessible to patient (can effectively disrupted / removed using toothbrush/ interproximal cleaning devices).

• Mechanical plaque control can be effective in preventing / reversing gingivitis.

• If patient unable to perform mechanical plaque removal – use of chemotherapeutic agents as an adjunct may be warranted.


TERMINOLOGY:- Plaque inhibitory effect: reducing plaque

to a level insufficient to prevent the development of gingivitis.

- Anti-plaque effect: produces a prolonged & profound reduction in plaque sufficient to prevent the development of gingivitis.

- Anti-gingivitis: anti-inflammatory effect on the gingival health not necessarily mediated through an effect on plaque.


Antimicrobial agents;- Antiseptics- Antibiotics

Miscellaneous agents;- Matrix protein- Growth factor- Hydrogen peroxide


Can be used: topically, locally applied & systemically

Can be used: topically, locally applied & systemically

ANTISEPTIC AGENTS

- Directed against supra-gingival plaque development

- Directed against sub-gingival bacteria


ANTISEPTICS• Topically (mouthwashes)- Oradex – chlorhexidine 0.12%- Listerine® antiseptic mouthwash (phenolic

compound/ essential oil)- Plax® (triclosan)

• Typically act supra-gingivally.


ANTISEPTICS• Locally applied- Slow release devices (biodegradable polymer,

gel, fibers, collagen)- Applied into periodontal pockets:

Perio Chip® (2.5 mg chloroxedine in gelatin matrix) Atrigel® (5% sanguinarine)

• Typically act sub-gingivally.


TOPICALLY ACTING CHEMICAL AGENTS• Requirement:- Effective in reducing plaque & gingivitis- Effective & remains for a sufficient amount of time to

accomplish the desired results (substantivity)- Without development of resistant bacterial strains or

damage to the oral tissues.- Cost-effective- Pleasant to use- Low toxicity – without adverse effects- High potency- Good permeability & intrinsic efficacy


ANTISEPTICS – Mouthwashes • Quaternary ammonium compound (cetylpyridium

chloride)• Hexidine – Bactidol®• Oxygenating agents – hydrogen peroxide• Amine alcohols – Delminol• Povidone iodine natural products – sanguinarines

• All these available either as mouthwashes, irrigation, toothpaste, gel/ spray.



TOPICALLY ACTING CHEMICAL AGENTS

CHEMICAL SUPRAGINGIVAL PLAQUE CONTROL

Bisguanides Chlorhexidine, Alexidine

Phenolic compounds Listerine, Thymol & other essential oils

Quartenary ammonium compound Amyloglucosidase, Glucose oxidase

Enzymes Cetylpyridium chloride, Benzalconium chloride

Oxygenating agents Hydrogen peroxide, Peroxyborate

Fluorides Sodium fluoride, Stannus fluoride, Sodium MFP

Other antiseptics Triclosan, Povidone Iodine, Hexetine

CHLORHEXIDINE• Bisguanide compound• Dicationic and strong base• Prolonged action• Concentration – 0.2% or equivalent• The only product to kill bacteria• Not act as anti-adhesive• Only can penetrate into thin plaque not thick

/mature (calculus) plaque.• Can inhibit the plaque formation but cannot

eliminate the plaque in untreated mouth.


CHLORHEXIDINE• Broad spectrum antiseptic which possess anti-

plaque activity.• Mostly available in digluconate salts formulations.• Strong base & dicationic at pH levels above 3.5

with 2 positive charges on either side of hexamethylene bridge.

• At low concentration – cause increase in cell membrane permeability & leakage of intracellular components.

• At high concentration – precipitation of bacterial cytoplasm & cell death.


PHENOLIC COMPOUNDS• Eg: Listerine ®• Have moderate plaque-inhibitory

effects & some anti-gingivitis effect.• Less effective than chlorhexidine but

more powerful than triclosan.


CHX - As a broad spectrum antimicrobial

agent, have no bacterial resistance reported & no evidence of superinfection by fungi / viruses.


INDICATION:• CHX m/w indicated to post perio-surgical patient to

reduce the bacterial load / to prevent plaque formation at time when mechanical cleaning may be difficult due discomfort.

• Patient with mental & physically disabilities lack of manual dexterity in;

- Parkinson disease- Adjunct to immunocompromised such as HIV/AIDS- Cerebral palsy• In this situation, advisable agent would be CHX m/w.


INDICATION:• CHX m/w can be prescribed to patient

wearing orthodontic appliance & also for patient with intermaxillary fixation following trauma / orthognathic surgery.

• As an adjunct to mechanical instrumentation in case such as refractory periodontitis & locally applied antimicrobial agents can be used.


LIMITATION:• CHX particular inhibit plaque formation

in a clean mouth but not significantly reduce bacterial load in untreated mouth.

• CHX m/w cannot penetrate into gingival crevice, therefore have no place in control of chronic periodontitis – presence of deep pocket of >5 mm.


LIMITATION:• CHX have local side effects such as;- Tooth & tongue staining- Staining tooth-colored restorations

(composite & porcelain)• Reversible parotid swelling• Numbness of tongue – taste disturbance• Bitter taste• Mucosal erosion are also reported


• Periodontitis can be classified by: Disease activity (chronic/aggressive) Cause (specific bacterial, fungal / viral infection) Site (localized or generalized) Extent (size & morphology defects) Type of associated gingivitis (chronic/necrotizing) Type of patient (child, adolescent, adult/ compromised)

• Non-specific plaque theory (reduction of bacterial load)• Specific plaque theory (specific plaque therapy)


ANTIBIOTICS1. Use of antibiotics (systemically / local application)

mainly directed against specific bacteria & sub-gingival plaque to target identified periodontal pathogens. Eg. In ANUG & localized aggressive periodontitis.

2. Antibiotics is directed against specific microorganisms, eg. AA in specific plaque hypothesis in ANUG/P & aggressive periodontitis.

3. While mechanical removal of plaque aimed at reduction of bacterial load for non-specific plaque theory.


ANTIBIOTICS4. If unresponsive pockets (after reassessment

therapy done & no response to therapy), chlorhexidine in slow release of polymer can be used locally, advantage of that, agents can be sustained release within the pocket. Locally applied antibiotics also can be used in this situation.

5. Used of antibiotics in periodontal abscess usually not necessary if the abscess only localized unless there are signs of spread of infection to systemic area / sign of cellulitis/ lymphadenopathy.


ANTIBIOTICS6.Post surgical rinsing with chlorhexidine

mouthwash mainly due to inability to mechanically removed plaque because discomfort.

7.Post surgical systemic antibiotic prescription may not indicated, unless complex surgical procedures been carried out (post-implant surgery) / patient is medically compromised.


ANTIBIOTICS8. Indication of use of antimicrobial

agents to patient with lack of manual dexterity or with patients with mental disability is clear.

9. Patient wearing orthodontics appliances cannot used chlorhexidine mouthwash for a long term due to tooth & tongue staining side effects.


Antibiotics agents:• Local application• Systemic use


ANTIBIOTIC – Local ApplicationAntibiotics can be in form of:• Gel – for topical application onto

surface or sub-gingival application.• May present in polymer.• Also present in the form of

biodegradable slow, release gel, hollow or solid fibers.


ANTIBIOTIC – Local ApplicationExamples:a.Elyzol gel - 25% of Metronidazoleb.Dentomycin gel - 2% of minocyclinec.Actisite – tetracycline fibers (hollow/solid)d.Periocline - 2% minocyclinee.Atridox - 42.5 mg Doxycyclinef. Arestin - 1 mg minocycline


ANTIBIOTIC – Systemic Uses• In the form of liquid, tablets or

capsules –suitable if patients diagnosed with aggressive periodontitis ONLY.

• Must finish antibiotic simultaneously with the therapy/ root debridement.


ANTIBIOTIC– Systemic Uses (Aggressive Periodontitis )

• Amoxicillin in combination with Metronidazole (if allergic to penicillin give clindamycin);

- 250 mg amoxicillin & 200 mg Metronidazole tds for 4 to 7 days.

• Tetracycline- 250 mg tetracycline for 14 days- Doxycycline 100 mg once a day for 14 days (double dose

for first day because half of it will bind to plasma & another half will be in blood).


ANTIBIOTIC – Systemic Uses(ANUG/P)• In case of ANUG/P, Metronidazole may be

needed for 3 – 4 days only.- 200 mg Metronidazole tds for 3 – 4 days.- Analgesic may be prescribed to patient

diagnosed with ANUG/P due to pain.- Since the ANUG/P lesions being very painful

to mechanical plaque control, chlorhexidine may be given.


ANTIBIOTIC – Systemic Uses• For post-surgical systemic antibiotic,

Metronidazole may be needed for 1 – 7 days.

- 400 mg Metronidazole tds for 1 day.- Analgesic may also prescribed.- Chlorhexidine mouthwashes must be

given since the wound may be painful to mechanical plaque removal.



ANTIBIOTIC – Systemic Uses• Periostat® is available as a- 20 mg doxycycline taken twice daily about

an hour before or 2 hours after meals.- Adjunct to scaling & root planning.- Act as collagenase inhibitor (degrade

collagen at periodontal ligament/gingiva but not to controlled the bacteria) at low concentration.

- Danger to develop bacterial resistance.- Take about a month.

INDICATION:• Antibiotic prophylactic agents in which the risks

of bacterimia & infective endocarditis is high.• Systemic antibiotics prescribed are directed

against specific microorganisms as an adjunct to mechanical instrumentation in aggressive periodontitis & ANUG/P.

• The used of systemic antibiotic without cautions can lead to development of bacterial resistance.

• Certain individual may suffered from immediate hypersensitivity which can be fatal.


General terms for a chemical substances provides a clinical therapeutic benefit.

CHEMOTHERAPEUTIC AGENTS

Regimen Dosage/Duration

Single Agent

Amoxicillin 500 mg tds for 8 days

Azithromycin 500 mg Once daily for 4 – 7 days

Ciprofloxacin 500 mg Twice daily for 8 days

Clindamycin 300 mg tds daily for 10 days

Doxycycline or Minocycline 100- 200 mg Once daily for 21 days

Metronidazole 500 mg tds for 8 days

Combination Therapy

Metronidazole + amoxicillin 250 mg of each tds for 8 days

Metrinidazole + ciprofloxacin 500 mg of each Twice daily for 8 days

COMMON ANTIBIOTIC REGIMENS TO TREAT PERIODONTAL DISEASES

COMMON ANTIBIOTIC REGIMENS TO TREAT PERIODONTAL DISEASES

Data from Jorgensen MG, Slots J: Compend Contin Educ Dent 21:111, 2000


Monocycline • Effective against broad

spectrum of microorganisms.

• Suppresses spirochetes & motile rods as effectively scaling & root debridement.

• Less phototoxicity & renal toxicity than tetracycline but may cause reversed vertigo.

Doxycycline • Same spectrum of

activity as minocycline & may be equally effective.

Metronidazole • Bactericidal to anaerobic

organisms & is believed to disrupt bacterial DNA synthesis in conditions with a low reduction potential.

• Effective against Porphyromonas gingivalis & provetella intermedia.

• Used in ANUG, chronic periodontitis & aggressive periodontitis

Clindamycin • Effective against

anaerobic bacteria.• Effective in situations

in patient is allergic to penicillin.

• Shown efficacy in patient with refractory periodontitis.


Ciprofloxacin • Quinolone active

against gram-negative rods, including all facultative & some anaerobic putative periodontal pathogens.

• Minimal effect on Streptococcus species.

• To fight AA.

Amoxicillin • Semisynthetic penicillin

with extended antiinfective spectrum that includes gram-positive & gram-negative bacteria.

• Used in management of aggressive periodontitis in both localized & generalized forms.

• Susceptible to penicillinase.


Amoxicillin – Clavulanate potassium

• = Augmentin• Useful in managing

patient with localized aggressive periodontitis or refractory periodontitis.

• This antiinfective agent is resistant to penicillinase enzymes produced by some bacteria.


Clinical diagnosis

Health Health Chronic periodontitisChronic periodontitis Aggressive, refractory or medically related periodontitis

Aggressive, refractory or medically related periodontitis

Periodontal therapy including:-Oral hygiene-Root debridement-Supportive periodontal treatment-Surgical excess for root debridement or-Regenerative therapy

-Antibiotic as indicated by microbial analysis

Microbial analysis

Effective Ineffective

Supportive periodontal treatmentSupportive periodontal treatment

Guidelines for use of antimicrobial therapy

Medically related, aggressive, or refractory periodontitis (diagnosis)

-Periodontal evaluation-Review medical history-Plaque sampling

Medically related, aggressive, or refractory periodontitis (diagnosis)

-Periodontal evaluation-Review medical history-Plaque sampling

Periodontal therapy

-Scaling & root planning-Place subgingival antimicrobials-Betadine irrigation-OHI-Periodontal surgery

Periodontal therapy

-Scaling & root planning-Place subgingival antimicrobials-Betadine irrigation-OHI-Periodontal surgery

Periodontal therapy

- 8 days regimen antibiotics at completion of root debridement if recommended by reference lab-Intraoral irrigation at home-Chlorhexidine rinse for 2 weeks

Periodontal therapy

- 8 days regimen antibiotics at completion of root debridement if recommended by reference lab-Intraoral irrigation at home-Chlorhexidine rinse for 2 weeks

Reevaluation

-Evaluation of response to therapy-Reinforce oral hygiene-Plaque sampling as clinically indicated

Reevaluation

-Evaluation of response to therapy-Reinforce oral hygiene-Plaque sampling as clinically indicated

Supportive Periodontal Therapy

-Periodontal evaluation-Review medical history-OHI-Scaling & root planning-Plaque sampling as indicated clinically

Supportive Periodontal Therapy

-Periodontal evaluation-Review medical history-OHI-Scaling & root planning-Plaque sampling as indicated clinically

Day 0 6 – 8 weeks Every 3 – 4 months

Sequencing of antimicrobial agents (modified from Jorgensen MG, Slots J: Compend Contin Educ Dent 21:111, 2000)

PHASE 2

Assessment of Periodontal Treatment Outcome• Periodontal Risk Assessment

PERIODONTAL RISK ASSESSMENT

DEFINITION:• Risk –

probability that an event will occur in the future/ probability that an individual develops a given disease.

Can divide into:- Risk factor- Risk indicator (determinant)- Risk predictor

• Risk Assessment – it is a process which qualitative / quantitative assessment are made of likelihood for adverse effect to occur as a result of exposure to specified health hazards, so it can be reduced, avoided / managed.


IMPORTANCE OF PRA• Periodontal disease is an imbalance of bacterial plaque & host

susceptibility.• Role of the bacteria as initiator to periodontal disease & 1o

etiology of periodontal disease.• Host – related factors (influence the presentation & progression of

periodontal disease).• All people are not equally susceptible to periodontal disease. (in

longitudinal study of Sri Lankan tea plantation)• All people are not equally response to periodontal therapy.(in

longitudinal study of well maintained 600 patients were followed for 22 years)

• Successful of periodontal therapy.- Early & corrective diagnosis- Risk management- Effective treatment

PURPOSE OF PRA


• Identify disease severity• Identify the patient likelihood of

developing the disease• Understand future disease

progression• For comprehensive treatment

planning.When To Perform:

1. To all new periodontal patient.2. After active treatment before Supportive

Periodontal Therapy

RISK TO LOOK FOR:


RISK FACTOR RISK INDICATOR RISK PREDICTOR

Biological plausible as a causative agent for disease.

Biological plausible as a causative agent for disease.

No current biological plausible as a causative agent.

Shown to precede the development of the disease in prospective clinical studies & longitudinal studies.

Where the associated only show by cross-sectional studies.

Shown to be associated with disease on a cross-sectional/ longitudinal studies.

Eg: smoking & diabetes Eg: patient with HIV/ age/ gender/ race/ osteoporosis/ genetic factors/ bacterial/ stress

Eg: markers/ historical measure of disease/ number of missing teeth.

CLINICAL PREDICTIVE FACTOR


TOOTH FACTOR BLEEDING ON PROBING

POCKETS DEPTH

• Tooth position• Caries• Defective restoration margin• Bacterial• Furcation• Type of bony defects

• Low BOP <25%: lower risk of disease progression

• Increased number of remaining deep pocket ≥ 6mm following Initial Phase Therapy : greater risk for disease progression

METHOD TO IDENTIFY INDIVIDUAL AT RISK

• Diagnostic test – Clinical parameters, PD, BOP & r/g.

• GCF analysis & saliva-oral microorganism, neutrophil defects, genetic markers & antibody.

• Subjective risk assessment – asking environmental risk.


PRA MODEL


RISK BOP (%)

PPD >5mm

TOOTH LOSS

BL/AGE SMOKING/ day

GENETIC/ SYSTEMATIC

LOW 0-9 0-4 0-4 0.05 - -

MOD 10-25 5-8 5-8 >0.05 – 1.0

10 - 19 -

HIGH >25 >8 >8 >1.0 >19 +

Coding System For PRA:

•LOW – all low risk + 1 MOD risk•MOD – ≥ 2 MOD + 1 HIGH risk•HIGH – ≥ 2 HIGH risk

Coding System For PRA:

•LOW – all low risk + 1 MOD risk•MOD – ≥ 2 MOD + 1 HIGH risk•HIGH – ≥ 2 HIGH risk

•BOP – bleeding on probing•PPD – periodontal pocket depth•BL – bone loss•MOD – moderate

•BOP – bleeding on probing•PPD – periodontal pocket depth•BL – bone loss•MOD – moderate

Coding System For PRA (Lang & Tonetti 2003)

BL/Age

• % of bone loss in the worst site of posterior tooth measured from PA / BW.

• Then devide it by patients age.• Eg. If a 40 year old man suffered 20% of

bone loss at mesial of 46:• 20/40 = 0.5 = LOW RISK


Periodontal Therapy (Full Version)

Documents

Transcript of Periodontal Therapy (Full Version)